A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, March 02, 2009

Thank Goodness for Case Management

I have no idea what Case Management is, but it's something that big insurance companies pay nurses (who can't or won't hack real nursing jobs anymore) with some of the money they aren't paying me.

Two weeks ago, I got a call from a Case Manager about an elderly, demented patient I hadn't seen in about a year. She had fallen, been admitted to the hospital despite having no fractures, and then transferred to a rehab facility. Her son had called me about all of this. Apparently she wasn't doing well at rehab, so they were supposed to send her back home. Her son had called to let me know this, too.

When I got the call from the Case Manager, I was trying to handle calls on two other lines at the same time, so I asked what she wanted.

Case Management RN: "I just want to give you my name and phone number."

Me: "Okay. Why?"

CMRN: "Because her insurance company offers case management services as part of her coverage."

Me: "Okay. But what do you want me to do?"

CMRN: "I'm going to fax you a form."

Me? "What for?"

CMRN: "Giving you my name and number."

Me: "Fine." click (I was really frazzled at that particular instant.)

I wrote down her name and number, and got a faxed form with her name and number, and a request for all kinds of information that I couldn't possibly provide, given that I hadn't seen the patient in about a year, so I stuffed it all into the patient's chart and ignored it.

Last week, the patient's son called to let us know his mother had died peacefully and to thank us for all we had done for her.

This week, I got a call from the Case Manager. She wanted to let me know the patient had died.

I don't know how much, or if anything the CM did in this case but I've heard great things about CMs in the sarcoma community for patients getting services that their insurance company denied them. CMs are supposed to be working for patients, not for the insurance company.

I haven't had to use one, and part of me still thinks that they are part of the greater evil, but I often hear how the 'experimental protocol x' finally got approved after the patient got a CM assigned to them.

From the patient perspective:I once got to hear my wife have a conversation with a nurse wanting to be her case manager. Despite being in her 20's, I guess my wife had enough chronic problems/meds to trigger the system (asthma, allergic rhinitis, migraines, GERD). Maybe she crossed the threshold where her medical care was costing the company money, rather the profiting the company like a normal twenty-something.

My wife kept asking her to explain what services the nurse would provide her that her PCP wasn't already providing. Finally the case manager gave up and just sent her a letter. It was mildly amusing.

Hate to break it to you, but case managers DON'T work for patients. Ever. They work for insurance companies and hospitals, and as noted above, basically try to shorten stays and minimize expenditures. For patients and doctors, they are useless PIA's. And a real nursing job is one where you (actually) take care of patients. There is some real nursing going on but it's pretty hard to find. Most of the degreed nurses are taking care of charts while aides and techs do most of the real work. Then there's the ones working for insurance companies, lawyers etc. The rest want to be nurse practioners and don't even get me started on them.

As the parent of a child with a case manager (supplied by my HMO), I couldn't be happier with her.She has helped me out in numerous ways, from appealing a denial, getting DME vendors to actually bill correctly to providing information and a shoulder to cry on.I have told her she in invaluable many times.